Carol McEwen

After leaving the company in February 2024, I returned as an Analyst handling Appeals in several markets initially, then handling Clinical Rx cases with perfect quality and production scores. My excellent grammar skills and knowledge of the insurance industry from both the provider and the insurance company perspectives made this a great position for me.

• After briefly moving out of state, I returned as a Claims Analyst II in 2019. I applied for a Quality Auditor II position in early 2022 and was promoted. I handled several markets auditing high dollar, individual focus and trainee claims with speed and accuracy.

• Hired as a level II as an outside candidate to recover overpayments from providers. I worked through documentation to identify the overpayment and with speed and accuracy, then adjust the payment accordingly.

• Hired in June 2015 to handle billing. Moved on to inputting charges, while working the A/R and posting most of the payments for the practice. I also audited medical records to ensure the physician is using the correct code based on the criteria. I handle high level appeals and grievances presented by patients.

• Hired as one of only a few adjusters from outside the company to handle first party medical payments and personal injury claims. Received, keyed and processed bills efficiently while ensuring providers were billing per AMA guidelines. Responsible for setting up and preparing files for Independent Medical Exams, which included asking physicians about specific injuries and their causality to an accident.

• Was responsible for managing a large caseload of bills and accounts for heart patients for this large practice. I ensured proper coding from the offices and sent claims to the appropriate insurance companies along with the proper medical documentation needed for proper payment. I also dealt directly with patients and answered their questions and concerns about their bills. Expertly handled appeals to insurance companies.

• Received and processed medical claims from providers and facilities that were of higher dollar amounts with a perfect accuracy score. Responsible for ensuring that the claims were coded appropriately and were paid or denied correctly per AMA and Optima guidelines. Promoted to senior processor and responsible for auditing other claims processors. Was often asked to help update the policy several times with verbiage that was processor friendly.

• Handled all aspects of auto accidents including the investigation into liability, property damage and evaluation and compensation of injuries. Often worked with attorneys and claimants to negotiate and settle the claim. Researched causality of injuries to damage and set up Independent Medical Exams if need be.